As lawmakers consider ways to overhaul the agency responsible for providing care for American Indians and Alaska Natives, one idea includes expanding tribal authority over hospitals serving them.

Under the Indian Self-Determination and Education Assistance Act, tribes are allowed to provide health services for members instead of the Indian Health Service under certain conditions. Currently, 354 of the 567 federally recognized tribes take this approach. The program allows IHS to transfer funding to the tribes for them to figure out how to best provide care, and requires them to report on quality monitoring and tribal health status. The program makes up $1.8 billion of the $4.8 billion IHS budget.

Mary Smith, the principal deputy director for the IHS, said in a June 30 news release that allowing more tribes to provide care for members was part of the vision of helping tribes achieve self-governance.

“IHS will continue to work with tribes interested in entering self-governance compacts in support of tribal sovereignty and self-determination, and in order,” Smith said.

The self-governance program is something lawmakers are looking into as the agency continues to struggle to provide healthcare for 2.2 million American Indians and Alaska Natives. Lawmakers have been concerned about reports coming out of the Great Plains area about babies being born in ambulances en route to faraway hospitals, a pregnant woman giving birth on a bathroom floor, and employees handwashing medical tools.

South Dakota Republican Rep. Kristi Noem, whose district includes one of the troubled IHS facilities, introduced a bill (HR 5406) to overhaul IHS that includes a provision to launch a pilot program putting tribes in charge of hospitals on their reservations and establishing a special governing board to make decisions about care. While the self-governance program already exists, Noem said in a recent interview that her bill would further push aside IHS while still allowing the U.S. to meet its treaty obligations.

“I don’t think IHS should be in the hospital business. They’re terrible at it,” Noem said. “That’s the genesis of my bill. … It would allow for longer-term contracts with providers that understand the challenges of delivering healthcare in these rural areas. I don’t believe that IHS knows how to run hospital facilities and they shouldn’t do it.”

For tribes that run their own hospitals, that would mean they would assume IHS’ responsibilities for not just providing services but also for recruiting and retaining providers, having a billing system in place, and establishing policies and protocols for care, which could present challenges for tribes.

Jerilyn Church, CEO for the Great Plains Tribal Chairmen’s Health Board, said in an interview that while the current self-governance policy provides tribes with flexibility to provide the care they want to see, pushing for further independence like Noem wants would mean Congress should give tribes additional funding. Church said that while tribes have become fed up with IHS’ pitfalls, poorer tribes, while still eligible to apply for self-governance, may face challenges in getting their own systems in place under the existing system. But even with those challenges, Church said that tribes running their own health services is not an insurmountable goal, regardless of income.

“They’re willing to take that risk to run their own program,” Church said.